More ENT

I am staying on the ENT service for at least the next week and maybe 2 weeks. The adventures will continue. I was actually schedule to go to vascular surgery for the next 2 weeks but the ENT service has asked me to stay on. This is great for me be cause I like working on ENT and the doctors are great. I imagine that they will give me a great letter of recommendation. 

Tomorrow is clinic and Mondays are usually very busy. At least the 4th year resident will be back from his vacation. We will see all kinds of throat, ear, nose problems. By the time these patients make it to ENT their issues are fairly serious. This is their final stop. In clinic often have to diagnose and give the patients bad news. Lots of cancer or other serious conditions. There are also less serious conditions like hearing loss, compacted ear wax, tonsillitis, etc. It should be a good day.

The thrills of surgery

I just got home. Today started at 4:00 am and it is now 9:00 pm. What a long day but the strange thing is that I loved it which makes the time a non-issue. Today was a surgery day. We had 3 cases.

The first case was a 18 month old female with neurofibromatosis which is a rare autosomal dominant genetic defect. If there is 1 parent with the effected gene, on chromosome 17 then there will be a 50% chance of the offspring inheriting the disease. What is the disease? It usually presents with cafe au lait spots (look like brown birth marks). There are a few different versions of the disease and variable degrees of severity. The most severe presents with multiple tumors, including acoustic neuromas causing deafness and brain tumors. 

This girl's doctors wanted to rule out tumors / hemangioma in the bronchi as she has continually had respiratory problems. We did a bronchoscopy which is a procedure that involves using a camera to explore the bronchi of the lungs and see if you find any pathology. This girl turned out to not have any pathology in the bronchi.

The second case was a 5 month old male infant that was born premature at 26 weeks to a mother who abused crack and drank lots of alcohol. This baby has never left the hospital and is very sick. Most likely this child will expire and if it does survive it will be a  miserable life. The baby has been on a ventilator his whole life and so we were doing a tracheotomy to make the ventilated breathing easier. 

Whenever you do anything medical / surgical with infants it is like working on a time bomb. They are so fragile and things can go bad fast. Plus all the surgical techniques and pharmacology have to be altered. I do not think I would like pediatric surgery or medicine of any kind. To me it feels like you are on the edge of disaster at all times. Both of the pediatric cases went fine but we did have some tense moments. Also it was hotter than Satan's rectal vault in the OR. When operating on infants you have to keep the room very hot because infants do not do well in surgery with added thermoregulatory stressors. If the body has to focus on maintaining normal temperatures the overall system does not do as well and the surgical outcomes are worse.

The final case was an unbelievable case. I was fortunate to be able to see and do part of this surgery. We were doing a resection of a parotid body tumor. The parotid gland is located in the face where last weeks surgery on the carotid body tumor was in the neck. In today's case we had to expose a lot of the neck anatomy but also the face anatomy. We exposed the facial nerve and had to be careful not to damage it. We were successful in protecting the facial nerves and arteries. This case took 6 + hours, it was long. We also had some bleeding issues and it became tense as we had to find the bleeding vessel and tie it off. This took some time and fancy maneuvering to avoid damage to the structures. DUring this time I was working the retractors to move structures out of the way so the chief resident could find the vessel. During this whole time we were battling against blood flooding out. It is amazing how calm everyone stays, which is not the case when doing surgery on kids. Ultimately, after 20 minutes we were able to control the bleeding by finding the bleeding vessel and tying it off.

At the end of the day I felt so charged and this makes me consider surgery. I entered medical school wanting to do surgery but I also wanted to see the rumored lifestyle and see how painful it is. The plot thickens as we look at surgery as an option.

Lectures

Today I had lots and lots of lectures. On Thursdays I have lectures all day. The good thing about the lectures is that I get to see friends from school who doing their surgery rotations at different places. There are about 30 of us. So it is a good time to get together and share stories and get caught up. 

Today's lectures were on breasts and pediatric surgery. A pretty well known breast surgeon gave us lecture about breast cancer and the surgical treatments available. I never thought I would say that I would get bored talking about breasts, but never say never. We basically covered all aspects of diagnosing and treating breast pathology. One of the newer concepts is that with certain forms of cancer they administer chemotherapy first and then remove the cancer surgically. They used to head straight to the OR and then do chemotherapy. However, they have found if they can shrink the tumor first it will require less surgery and does not increase mortality of the patient. Another new concept is that they do not recommend self breast exams anymore. Most of the recent data suggests that self breast exams do not decrease breast cancer mortality and in fact increase the amount of unnecessary surgeries. It is still recommended to get regular breast exams done by your physician. Regular mammograms are recommended after 40. 

We also had a lecture series on pediatric surgery. I do not find pediatric surgery very interesting. We basically covered all the common surgeries seen in kids like inguinal hernias, pyloric stenosis, etc. I would have rather been in the OR learning about these with hands on experience. 

Tomorrow we have 5 surgeries, so it is going to be a long day. I am excited and love the OR. The best surgery tomorrow is a neck tumor removal. This tumor is huge, it is almost as big as the patient's head and highly vascularized. There will be lots of blood which means I will get to tie off lots of blood vessels. It should be cool.

I Like Surgery

Today we had several surgeries. Again it was a 13+ hour day but I am loving every minute of it. We had 2 tonsillectomies, 1 uvuloplasty, tracheotomy and a mandible reduction. Good times! I really like doing surgery and the residents who run the ENT program are more than happy to let me help with the surgeries. I feel like I could work all day in the OR, which is a good thing because that is what they require.

The first case we did today was a 22 year old male who over the weekend found himself in a fight and his jaw was broken into pieces by a fist. So we had to put it back together again and wire his jaw shut. Throughout the entire procedure I kept thinking to myself that his mouth is going to kill for the next week or so. In order to work on the jaw we had to use metal retracting tools to keep his mouth open and his tongue out of the way. You can't be gentle, so we were tugging and pulling and I have to imagine his mouth / tongue are going to be bruised. In order to wire the jaw shut we took wire and pushed it through the gums between the teeth, then you wrap it around a tooth and come back around the tooth through the gums again. It looked painful. I hope to never break my jaw.

The tracheotomy was a sad case. The patient is a 44 year old male with aggressive esophogeal / laryngeal cancer. We were doing a tracheotomy to insert a breathing tube. Basically you cut through the tissue and into the trachea about 2 finger widths above the sternal notch. We then insert a breathing tube. This patients cancer is so advanced that his entire neck is 2 - 3 times normal size due to all the cancerous growth. He is going to die shortly. I was looking at him after the procedure before the anesthesiologist woke him up and he already looked dead. His life has been sucked out of him by the disease. It is certainly hard to see and even difficult to comprehend. The guy probably has less than 6 months to live but could last longer so the torture will continue. Do you want to go for a smoke break?

ENT Clinic Day

Today started at 5:30 am and I just got home at 8:30 pm. I have to be back at the hospital tomorrow morning by 5:30 am for surgery which means I will leave home at 4:00 am. This is that lifestyle I was talking about. If I am on call tomorrow then I will have to stay at the hospital overnight and essentially work a 36 hour shift.

Today was a clinic day I worked with a 2nd year resident and a 5th year resident. We saw 90 patients today. I saw 34 patients myself. ENT clinic mostly deals with patients who have had ear problems, neck masses, mouth cancers, sinus problems, vocal cord issues, swallowing problems and nasal problems that can't be resolved by their primary care physician. Thus by the time the patient ends up in the ENT clinic they have a real issue which is often serious. Today I diagnosed and or informed 4 patients that they had cancer. Most of these were mouth cancers which tend to be very aggressive. We had to set these patients up for surgery to remove the cancers. 

I did several nasoscopes today. This involves taking a scope with a camera on it and feeding it through the patient's nose to visualize the sinuses and ultimately the larynx and vocal chords. I like doing procedures. Procedures also pay very well, specialties that do procedures tend to make more money. For example if a patient comes to the doctor with a chief complaint of congestion and the physician diagnosis acute sinusitis and prescribes an antibiotic the reimbursement will be somewhere around $150.00. If the doctor performs a nasoscope procedure on the same patient to rule out other pathology the reimbursement would be around $600.00 and would not take much more time. For the most part ENT surgeons are the doctors who do nasoscope procedures. Nasoscopes are very helpful for finding nasal polyps or cancers and throat nodules / cancers. Also they help diagnosis sinusitis. 

Today we had a 52 year old african american female who had an onset of bilateral ear pain that started 2 months ago. She had visited the ER 6 times and visited 4 different doctors at clinics over the last 4 months complaining of ear pain. Each time her ears were looked at with an otoscope and appeared normal. She had a 2 CT scans that were normal yet the pain continued. The last doctor she visited prescribed her antibiotics as a last ditch effort even though there did not appear to be an infection. 

The patient took the antibiotic drops for 8 days but did not like the way the drops made her ear feel. She said that it made hers ears and face numb and drove her crazy. She discontinued the medication because of these side effects. She noticed that her ear pain had subsided for a couple of days but was coming back. She returned to the doctor who this time referred her to the ENT clinic. I performed a nasoscope procedure and found 2 nodules on her vocal chords. Everything else about the exam was normal. Her tympanic membranes were intact without any inflammation or signs of infection. I showed one of the residents the nodules on the vocal chords. He agreed with my assessment and we scheduled the the surgery to excise and  biopsy the nodules. If the nodules are cancerous then more surgery and treatments will be required. If the nodules are benign then no further surgery or treatment will be needed. This patient is a great example of the kinds of patients that ENT doctors see.

The Surgeon's Lifestyle

What is the problem with a surgeon's lifestyle? The most obvious issue is that as a surgeon you are basically on call 24 hours / day unless you have partners and you share the call responsibilities. Usually the call schedule in groups like these are something like every 3 - 4 days the surgeon is on call and the other days are covered by the other surgeons in the group. These call days can be and often are hellish. Basically the surgeon ends up working 24 hours on those days because he/she will invariably get calls several times through the evening. 

The other issue is that the regular work days are fairly long and dictated by surgeries that always run longer than planned. You can't say, well it is 5:00 pm so I am going home when you are in the middle of a surgery. The average work week for surgeons runs between 60 hours to 80 hours depending on the type of practice. It is generally accepted in the field of surgery that work has to be the number 1 priority in a surgeon's life, not family, not hobbies and not religious commitments. Not all surgeons are this extreme but even the more mild surgeons are definitely more tied to their work than say a teacher, salesman or an engineer.

In all fields of medicine many hours are often required but for some reason surgery is notorious for the long hours and lifetime commitment. This is one of the major drawbacks to being a surgeon. These are some of the things I have to take into account as I try to decide what area of medicine I want to go into.

Death Of a Generation

On ENT service you see a lot of head and neck cancer. These are usually very aggressive cancers that progress rapidly and kill. These cancers also like to kill young people. Today I rounded on 6 patients all under the age of 40 with death at their door. Each of these patients have throat / mouth cancers and will die in the next year or so. They will have a variety of surgeries to try to put off the inevitable. 

Why do people get these cancers? Nearly 100% of the time these are caused by smoking and or drinking. The combo is a deadly duo. I wish I could video tape my interactions with these patients and show the misery that is cancer and death. Today we had to do a tracheotomy in a 34 year old male with tongue cancer so that we could hook up to a breathing device and prepare him for surgery next week where we will remove a large section of his mandible and tongue. I am sure when this guy took his first smoke at the age of 15 he did not see this in his future. It is interesting to see the staff interact and they say things like "he should not have smoked" and then seem to feel better about it. However the guy is still going to die and it is still unfortunate and regardless of the perceived reasons for the disease someone is still going to lose their dad, brother, best friend etc. I do not find any comfort in thinking the patient brought this upon them self. It still sucks. We all do unhealthy things. 

One thing I have noticed is that it is human nature to want an explanation for a disease or terrible circumstance. It helps us sleep better to know the patient is going to die because of x, y or z. In some way it distance us from the disease and makes us think it won't happen to us because we do not do x, y or z. 

I like ENT, I like surgery which puts me in a predicament because the surgery lifestyle is definitely a time consuming, busy lifestyle which tends to not leave a lot of time for other things. I will continue to learn and search and see if there is a way to be a surgeon and still have a life. There is nothing like walking into the OR scrubbed in and sterile and ready to operate. The rush, the feeling and the adrenalin do not seem to get old. Even the older surgeons still have that look and feel as they come in to operate and I think that is what keeps them coming back.